Telenursing in the postoperative period: a scoping review

ABSTRACT Objectives: to map available evidence on telenursing use in the postoperative period and its impact on patient outcomes. Methods: a scoping review, conducted according to the JBI model and the PRISMA-ScR checklist. The search was carried out in the CINAHL, Embase, LILACS, PubMed, Web of Science, SciELO, Scopus and Cochrane Library databases. Results: twelve studies were included, published between 2011 and 2023, 66.6% of which were in developed countries. Of the positive outcomes, we highlight improved levels of disability, autonomy and quality of life, lower rates of post-operative complications, pain and reduced costs. Telephone monitoring was the most widely used modality, but there were few studies in the pediatric context and in Brazil. Conclusions: of the studies, 11 (91.6%) identified at least one positive outcome in telenursing use and none showed negative aspects in the postoperative period. The role of nurses in digital health needs further study.


INTRODUCTION
Remote care for users of healthcare services has been applied for various purposes, from screening to rehabilitation, reducing waiting times for appointments and travel costs.In this regard, it is possible to develop educational activities to prevent, monitor and control the symptoms of patients treated through this modality (1) .
Telemedicine, a term created in the 1970s, denotes "remote healing" and deviates from the traditional visit between a doctor and a patient (2) .According to Darkins and Cary, telemedicine is defined as the use of advanced telecommunications technologies with the aim of exchanging information and providing healthcare services in areas with geographic, temporal, social and cultural limitations (3) .Telehealth can be defined as any intervention in which clinical information is transferred remotely between patients and healthcare professionals (4) .
In the context of nursing, in mid-2004, several telenursing services in Canada, England and Wales already had the method implemented (5) which, like telemedicine, is one of the methods of monitoring healthcare users with specific role of nurses.
Telehealth care, led by nurses, was expanded with the advent of the coronavirus disease (COVID-19) pandemic, which had as its strengths care provided without the risk of transmission of SARS-CoV-2, greater access to healthcare, continuous and patient-centered care and increased satisfaction among patients and nurses (6) .
In Brazil, during the COVID-19 pandemic, the Federal Nursing Council (COFEN -Conselho Federal de Enfermagem), through Resolution 634 of March 26, 2020, authorized and standardized nursing teleconsultation (7) and, in 2022, the COFEN Resolution 696, amended by COFEN Resolutions 707/2022 and 717/2023, standardized the role of nursing in digital health within the scope of the Brazilian Health System as well as in supplementary health (8)(9)(10) .
The R esolution brings autonomy to nurses' work in digital health and regulates telenursing practice encompasses nursing consultation, interconsultation, consultancy, monitoring, health education and acceptance of spontaneous demand as specific interventions mediated by the use of information and communication technologies (ICTs) and in accordance with the General Data Protection Law (GDPL) (8)(9)(10) .
Research conducted in Canada (11) , the United States (12) and the Netherlands (13) indicates the use of different strategies, such as telephone calls, text messages and video calls.Such strategies have been implemented by nurses to improve patient outcomes in the postoperative period, such as increased user satisfaction, reduced visits to hospital services due to lack of assistance, quality of care and reduced costs associated with the long distances traveled by patients to access in-person care (11)(12)(13) .
The relevance of the topic in the entire context of perioperative nursing stands out.However, some factors still need better understanding in their implementation stages, highlighting the different strategies used and their beneficial aspects for patients in the postoperative period.

OBJECTIVES
To map the available evidence on the use of telenursing in the postoperative period and its impact on patient outcomes.

Ethical aspects
The scoping review does not require a request for an opinion from a Research Ethics Committee, as it is a secondary study and does not directly involve human beings.Therefore, in this research, no ethical assessment was carried out, in accordance with Resolution 466/2012 of the Brazilian National Health Council.

Study design, period and place
This is a scoping review, conducted in accordance with the JBI (14) methodology for scoping reviews, whose purpose is to provide a map of evidence on a given topic, identify knowledge gaps, support the development of new studies as well as identify and clarify concepts/definitions used in the literature about a given object.For its execution, the following procedures were adopted: research question elaboration; inclusion and exclusion criteria definition; literature search and article selection; data analysis, synthesis and presentation (14) .
It is noteworthy that we included evidence and methodological quality assessment, although it is not recommended in scoping reviews.
The process of identifying articles until the final sample was synthesized and presented following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) recommendations (15) .This is the first stage of study aimed at obtaining scientific foundations to develop and implement a telenursing protocol aimed at patients in the postoperative period of cranial surgery.

Research question elaboration
The PCC (14) strategy was used to develop the guiding question: Population (P): surgical patients; Concept (C): telenursing; Context (C): outcomes in the postoperative period.
Thus, the following research question was created: what evidence is available on the use of telenursing in the postoperative period and its impact on patient outcomes?

Inclusion and exclusion criteria
We included (I) original articles related to the guiding question of the study, (II) covering adult and pediatric audiences, (III) in different surgical contexts.
We excluded (I) review studies, (II) qualitative studies, (III) cross-sectional studies, (IV) simple and expanded summaries, (V) posters, (VI) editorials, (VII) duplicate studies, (VIII) studies that started monitoring 30 days after surgery and (IX) studies not carried out by a nurse.(WoS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scientific Electronic Library Online (SciELO), Scopus, Embase and Cochrane Library databases.

Data search, selection, extraction and presentation of evidence
The strategies were constructed with the help of a librarian, adapted for each database, using descriptors and their synonyms: (Telenursing OR Telemonitoring OR "Remote Consultation" OR "Consultation, Remote" OR Teleconsultation OR Teleconsultations) AND ("Perioperative Nursing" OR "Surgical Nursing" OR "Nursing, Perioperative" OR "Perianesthesia Nursing" OR "Nursing, Perianesthesia" OR Nursing OR "Postanesthesia Nursing") (Supplementary Material).
The studies were selected on a single day in August 2022.The reading took place from August to October 2022, and the search was reviewed in September 2023 in all databases, without fixing the year and language of publication, independently selected by two reviewers, using the Rayyan ® selection platform, developed by the Qatar Computing Research Institute (QCRI) as an auxiliary tool for archiving, organizing and selecting articles (16) .
In both moments of literature search, articles were selected after reading the titles and abstracts.Those that met the eligibility criteria and reached consensus between the two reviewers were read in full to define inclusion or exclusion from the review.Disagreements that occurred in the complete reading phase were discussed and resolved by a third reviewer.

Research strategy, evidence selection and data extraction
To collect data from selected studies, the instruments proposed by the JBI model were used according to study design.A standardized form was adapted by the authors containing: author(s); year; country; language; study design; multicenter or single center; level of evidence; objective; age group; specialty; type of intervention; and outcomes.In light of the COFEN Resolution, studies were classified following the different telenursing modalities established in Brazil (8)(9)(10) .

Analysis of evidence, presentation of results
To assess the classification of evidence from studies, the proposal by Melnyk and Fineout-Overholt was adopted (17) , which allows researchers to analyze different types of methods guided by the following criteria: I for systematic reviews and meta-analysis of randomized clinical trials; II for randomized clinical trials; III for non-randomized controlled trial; IV for case-control or cohort studies; V for systematic reviews of qualitative and/or descriptive studies; VI for qualitative or descriptive studies; VII for opinion from authorities and/or reports from expert committees.This hierarchy classifies levels I and II as strong, III to V as moderate, and VI to VII as weak.

Methodological quality assessment
Two reviewers independently assessed the quality of the studies for risk of bias, and disagreements were resolved through consultation with a third reviewer.For cohort studies, we assessed study quality using the Newcastle-Ottawa Scale (NOS) (18) .
The NOS for cohort studies is composed of eight items.Each item can receive one point (one star), except the "comparability" item, whose score varies from zero to two stars.Low risk of study bias can receive a maximum score of nine stars for cohort studies.Cohort studies with six to eight stars were rated as moderate, and those with five stars or less were rated as low quality.
For clinical trials assessed, the risk of victory was assessed using Cochrane Collaboration (19) , according to the following criteria: generation of desired sequence (selection bias); allocation concealment (selection bias); blinding (performance bias and detection bias), considering blinding of participants and personnel and blinding of outcome assessment; incomplete outcome data (attrition bias); selective reporting (reporting bias); and other biases.

Inclusion
Regarding study design, 10 (83.3%) were characterized as randomized clinical trials, classified as level of evidence II, and cohort studies (n=2; 16.6%), classified as level of evidence IV.In relation to study execution, nine (75%) were carried out in single centers, and three (25%) in multicenter centers.The total population of all included studies was 2,098.
A (8.3%) study, which aimed to assess the impact of telenursing on symptoms and quality of life in patients undergoing esophageal and stomach resection surgery, correlated the comparison between intervention and control groups regarding symptoms, quality, distress, pain, admissions to emergency services and patient satisfaction.In this study, it was verified that, of the 81 patients assessed, there was no statistically significant difference between the control and intervention groups in relation to symptoms, quality of life, pain and distress during the proposed pre-and postoperative monitoring.Regarding search rates for emergency services and readmission, it was evident that there was a significant reduction in demand for the intervention group, although there was no statistical significance (30) (Chart 1).
Charts 2 and 3 present the risk of bias assessment according to the specific scales Cochrane Collaboration (19) for randomized clinical trial studies and modified NOS (18) for cohort studies.
Of the ten randomized clinical trials, five (50%) were considered to have a low risk of bias, four (40%) to have an uncertain risk of bias, and one (10%) to have a high risk of bias.Cohort studies presented seven stars, considered of moderate quality.

DISCUSSION
As one of the telenursing actions, monitoring is identified as an innovative tool in the healthcare segment, which favors users' accessibility to healthcare services, and should be used as a complement to healthcare, with the aim of promoting better access conditions, not replacing actions already carried out in person in healthcare services (31) .
Telenursing, in the post-operative period, proves to be a fruitful, innovative and challenging activity, which requires nurses to have scientific knowledge, technical skill and creativity, and can be used in the nursing process, in addition to the opportunity to promote health literacy.In this context, this study showed the predominance of monitoring as a strategy for providing care to post-operative patients at home.Among the main interventions, telephone calls (1,(21)(22)(23)(24)(25)(26)(27)(29)(30) and text messages (20,28) stand out. The oucomes identified in the studies are diverse and also differ between the groups of surgeries and patients assessed.
As outcomes related to the surgical experience, telenursing favored self-care in the dimensions of general self-care skills, self-care skills developed and self-care skills developed with poor health status and total scores on the Appraisal of Self-Care Agency Scale (21) .Regarding the resumption of activities of daily living, telephone interventions brought significant results in the functional autonomy of elderly patients, measured by the Functional Autonomy Measurement System (SMAF) (25) .A randomized clinical trial, carried out in China, including 100 patients in the postoperative period of head and neck surgery, compared telephone monitoring versus traditional monitoring.The results show that telenursing increased health knowledge and behaviors (12.52±9.27 vs. 5.94±8.12;P<0.001 (21) .A study conducted in Brazil considers that the telephone approach is a strategy for promoting health (1) .
Telenursing has been shown to be beneficial for different patient outcomes in the postoperative period of lumbar disc hernia surgery.A randomized clinical trial with 33 patients in the intervention group and 34 in the control group aimed to compare the effect of walking supported by a pedometer through monitoring with a telephone call three weeks and after the completion of the first, second and third months postoperatively.The outcomes assessed were levels of pain, disability and quality of life.The results show that walking after surgery reduced pain and disability levels and increased quality of life (24) .Considering the pain outcome, patients in the intervention group showed a reduction in levels of sensory-perceptual pain, momentary pain and verbal pain measured by The Short Form McGill Pain Questionnaire (SF-MPQ) in the second and third months after surgery (24) .
Another study that assessed quality of life in 86 patients undergoing minimally invasive esophagectomy showed that telerehabilitation (rehabilitation guided by a messaging application called WeChat ® ) contributes to improving participants' overall quality of life according to The European Organization for Research and Treatment of Cancer Quality of Life (QoL) Questionnaire Core 30 (EORTC QLQ-C30) (22) .A multicenter randomized clinical trial, conducted in eight Canadian hospitals, including 905 post-operative patients from different surgeries, compared virtual care (telephone call and automated remote monitoring) versus in-person care for 31 days.It was found that participants in the virtual care group had lower levels of moderate to severe pain at 7 (58.8%),15 (48%) and 30 (35%) days postoperatively.However, there were no differences between the groups when analyzing the effect of interventions on patient complaints and hospital readmissions (24) .An Australian pilot study, with six months of follow-up of 75 patients in the postoperative period of colorectal surgery, also indicates that telephone calls are effective in improving quality of life (30) .
User satisfaction was the outcome assessed in three studies (1,23,26) .Research conducted in Brazil, including 81 patients undergoing gastrosurgery, showed that 87.5% of patients rated the service provided by telephone monitoring as excellent versus 53.3% of patients in the control group (in-person service), with p=0.002 (1) .
A multicenter study, using the Patient Satisfaction Questionnaire -18 (PSQ-18), aimed to determine whether patient satisfaction in virtual meetings is not inferior to satisfaction in traditional in-person meetings for patients undergoing reconstructive surgery for pelvic organ prolapse.Fifty-two participants were included in the study and randomly assigned to two groups.The mean patient satisfaction score was 80.7 ± 2.6 in the virtual group and 81.2 ± 2.8 in the office group, consistent with non-inferiority.Postoperative complication rates were 31% in the virtual group and 46% in the office group.There were no significant differences between office visits, emergency room visits, and hospital readmissions within 90 days of surgery (26) .
A randomized clinical trial, developed in China, with 103 participants undergoing colostomy, showed that there was no significant difference between the control and intervention groups in the level of initial satisfaction.However, one month and three months after discharge, the intervention group showed significantly greater satisfaction (23) .
Other studies (23,26) that assessed patient satisfaction in different surgical contexts presented similar results in relation to in-person and remote care, however the time factor was better assessed by participants.The time spent by users to go to the office, the waiting time for the service to begin and the time taken to return home were the main dissatisfactions reported.As a result, remote care duration, excluding travel time, was almost a third shorter compared to the group with in-person care (23,26) .A study focusing on cancer patients showed that telephone monitoring provided greater patient satisfaction in the intervention group, demonstrating the real impact of this process on cancer patient care (1) .
Supporting the study, the literature points to other benefits of telenursing associated with satisfaction, such as reducing barriers to accessing services, timely counseling and nursing care provided by nurses remotely, providing users with training to exercise control over their recovery process (22)(23)25,(32)(33) .
Telenursing's contribution to adequate use of emergency units by patients in the postoperative period is considered a still controversial outcome that needs to be better studied.A Brazilian study, monitoring patients with esophageal and stomach cancer for nine months postoperatively, found that, among the 40 patients in the control group and 41 patients in the intervention group, there was no reduction in the number of admissions to the emergency department (1) .Differently, a study carried out in the postoperative period of prostatectomy showed that patients in the intervention group showed a reduction in the search for emergency services when compared to the control group (34) .An Australian pilot study, with six months of follow-up of 75 patients in the postoperative period of colorectal surgery, also indicates that telephone calls are effective in reducing hospital readmission rates and demand for emergency services (30) .
In the present study, the specialty of gastrosurgery stands out, which was the object of study in six studies focusing on telenursing (1,20,(22)(23)28,30) , of which three (20,23,28) addressed the surgeries to perform colostomy/jejunostomy. As fr ostomy care, a clinical trial carried out in Iran, with 64 patients, found that, after one month of the intervention, with telephone calls and SMS messages, there was a significant difference between the two groups when comparing stoma adjustment and its dimensions (p<0.001)(28) . In line wth this result, a randomized clinical trial, with 103 participants, carried out in China, assessed patients in relation to the Ostomy Adjustment Scale (OAS) and Stoma Self-Efficacy Scale (SSES).Participants in the intervention group, in the third month, had significantly better ostomy adjustment and greater stoma self-efficacy compared to the control group (p=0.006)(23) .
Regarding aspects related to mental health, a study assessed depression and anxiety three months after discharge from postenterostomy surgery using the WeChat ® strategy (text messaging).Using self-assessment instruments for anxiety (Self-Rating Anxiety Scale (SAS)) (p=0.017) and depression (Self-Rating Depression Scale (SDS)) (p=0.012), the results show that the intervention group presented a statistically significant difference in the SAS and SDS scores when compared to the control group (20) .Research that analyzed, for six months, the effects of monitoring on 119 patients undergoing permanent colostomy, found that both groups presented better SAS and SDS scores post-intervention when compared to pre-intervention (the control group presented pre-intervention SAS of 61.02±7.48 and post-intervention of 53.38±6.12 and preintervention SDS of 60.29±7.21and post-intervention of 52.07±4.26; the observation group presented SAS pre-intervention of 61.82±6.21 and post-intervention of 49.83±5.44 and SDS pre-intervention of 59.87±6.44 and post-intervention of 47.96±4.79) (35).
One gap identified is the carrying out of studies including the pediatric population.A single study carried out with infants, a retrospective cohort, with 308 patients, assessed discoloration, erosion, erosion and tissue overgrowth (DET), proving that the intervention group had a lower DET score (p=0.003) and required fewer colostomy bag replacements three months after hospital discharge (p=0.002) when compared to the control group (20) .
Although telenursing shows promise for monitoring surgical patients, there is a need for further investigation, considering different scenarios and methodological rigor in carrying out studies.This modality favors access to information and, consequently, provides better health results.Discussion between peers enables support between specialists, which promotes increasingly assertive action, reducing the risk of harm resulting from healthcare and favoring significant learning for the nurses involved (36) .
It is also worth highlighting the scarcity of studies conducted in Brazil, a gap that must be filled in light of COFEN Resolution 696/2022 (8)(9) . of Telenursing in the postoperative period: a scoping review Gimenez VCA, Almeida GMF, Cyrino CMS, Lemos CS, Favoretto C, Avila MAG.Finally, it is observed that no study was aimed at patients in the postoperative period of cranial surgery, signaling the importance of the study being developed by researchers who are implementing a protocol for monitoring via video call aimed at adult and pediatric patients in the postoperative period of neurosurgery.

Study limitations
As a limitation of this study, we highlighted the exclusion of review, qualitative, editorial, theses and dissertations studies.We also do not register with the Open Science Framework (OSF).Furthermore, the quality of the monitoring protocol used in the studies was not assessed, an extremely relevant aspect that could interfere with the outcomes.

Contributions to nursing, health, or public policies
Telenursing is a health technology that can further strengthen the autonomy of the nursing professional, highlighting their competence and relevance in the multidisciplinary team for making assertive decisions and a significant contribution to health promotion, prevention, and control of diseases, whether in individual or collective settings.

CONCLUSIONS
Of the studies identified in this review, none presented negative aspects related to the use of telenursing and 11 (91.6%)identified at least one outcome with statistical significance in the use of telenursing versus in-person care in healthcare services for patients in the postoperative period.The outcomes identified were improvement in disability levels, autonomy and activities of daily living, self-care skills, quality of life, improvement of health knowledge, user satisfaction, stoma management, reduced need for acute care, lower rate of adverse events and postoperative complications, reduced pain levels, improved anxiety and depression assessment scores, mental health levels and reduced costs.
Telenursing was most used in developed countries, and monitoring was the most used modality for assessing patients postoperatively.
In this way, a promising and relevant scenario for nurses' work is observed, with the need to develop new studies that include the development of protocols that meet the needs of each service/specialty and the beneficial aspects in quality of care in the postoperative period.
Study search was carried out in the Latin American and Caribbean Literature in Health Sciences (LILACS), National Center for Biotechonology Information (NCBI/PubMed), Web of Science of Telenursing in the postoperative period: a scoping review Gimenez VCA, Almeida GMF, Cyrino CMS, Lemos CS, Favoretto C, Avila MAG.

Figure 1 -
Figure 1 -Flowchart of the selection and inclusion process of PRISMA-ScR studies -2023

Telenursing in the postoperative period: a scoping review
Gimenez VCA, Almeida GMF, Cyrino CMS, Lemos CS, Favoretto C, Avila MAG.Assessment of the risk of bias in randomized clinical trials based on the Cochrane Collaboration Scale, Botucatu, São Paulo, Brazil, 2024 Assessment of the risk of bias of cohort studies based on the Modified Newcastle-Ottawa Scale, Botucatu, São Paulo, Brazil, 2024 Gimenez VCA, Almeida GMF, Cyrino CMS, Lemos CS, Favoretto C, Avila MAG.